NHS Just Culture algorithm in the Vanderbilt case

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Reference no: EM133975616

Question

Using the template in the class materials, apply the NHS Just Culture algorithm in the Vanderbilt case. Go step by step. Submit the paper as an appendix. What is conclusion (reference the appendix)?

What was the role of governance before, during and after the event in the Vanderbilt case?

Using the IHI Cause and Effect diagram, fill in the blanks for the Vanderbilt event. Use the fill and save mode or draw a diagram. Submit the paper as an appendix. Describe the contributing factors that led to the event and reference the appendix.

Identify human factor engineering issues found in the Vanderbilt case. What is a forcing function that a health care system could put into place to prevent another such error? Address the automatic dispensing machine in particular.

Reference no: EM133975616

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